"APTA applauds the proposed legal settlement of the nationwide class action lawsuit directed toward ensuring Medicare coverage of reasonable and necessary therapy and nursing services for people with chronic and degenerative health conditions," says APTA President Paul A. Rockar Jr, PT, DPT, MS, in a statement issued today regarding the lawsuit Glenda Jimmo, et. al vs. Kathleen Sebelius. Plaintiffs in the lawsuit alleged that the US Department of Health and Human Services, Medicare contractors, and administrative review boards were arbitrarily limiting coverage for patients who did not show long-term improvement in their conditions, even though official Centers for Medicare and Medicaid Services rules state these services should be covered.

Under this proposed agreement, Medicare would pay for skilled therapy and nursing services if they are needed to maintain the patient's current condition or prevent or slow further deterioration.

The New York Times highlighted how the policy change will result in significant cost savings in the long term by allowing patients to receive physical therapy and other services in community-based settings and avoiding expensive care in hospitals and nursing homes.

APTA will continue its efforts to ensure access to appropriate physical therapy services. The association also will work with the Centers for Medicare and Medicaid Services and its contractors to ensure accurate and fair incorporation of revisions to the current Medicare manuals and regulations that reflect this significant change. In addition, the association will continue to analyze the proposed settlement for potential impact on Medicare policies regarding the reporting of functional limitations on the claim for outpatient therapy and the requirement to complete a functional reassessment at defined intervals under the Home Health Part A benefit.

APTA plans to actively educate members to ensure proper understanding and application of the newly revised Medicare regulations.

Comments

Will this eliminate the therapy cap for out patient pt(in a non pt setting) i am a patient and follow this blog. I was forced to end PT because I reached the cap. Despite suffering a new injury I could not get more than a month of coverage for that. So, in many ways im worse now than before and counting down until January. It is confusing to me if I would be included in this ruling.

Posted by rachel
on 10/24/2012 11:51 PM

Hi Rachael,
This ruling has to do with Maintenance Therapy.
Some clinics impose limits on care due to the just-overturned, illegal Medicare Improvement Standard.
You're asking about the Medicare Caps which also limit care.
Unfortunately, many corporate-owned and physician-owned physical therapy clinics have elected to limit care based on the Medicare cap rather than consider individual factors, like in your case.
This ruling will not eliminate the Medicare cap.
Many therapist-owned clinics are willing and able to consider individual patient factors, such as your new injury, when applying for pre-approval to exceed the Medicare cap.
This ruling overturns the illegal Improvement Standard, which for the last 30 years, has said that physical therapists must discharge patients when their improvement "plateaus".
Tim Richardson, PT
www.PhysicalTherapyDiagnosis.com

Posted by Charles Richardson -> =GR^EM
on 10/25/2012 1:55 PM

Do we still need to send Medicare documentation for Manual Medical Review when services are above $3700.00 threshold?

Posted by Bryan Del Rio -> >OX]AG
on 10/25/2012 4:16 PM

I am an experienced clinician of 17 years board certified in orthopedics therapist with a 3 year manual therapy residency program under my belt and an employee of a large company that has excel slid ethics. I would like you to know that many organizations like ours routinely take the extra steps documentation wise to continue care when appropriate and well documented. Tim I am not sure where the bias against larger organizations comes from but I think it's an unfair characterization to phrase your answer as such.
Rachael an organization large or small is only as good as its people
Sam

Posted by Sam runfola
on 10/26/2012 6:38 PM

Some years back CMS allowed for maintenance treatment if the condition would require the skills of a PT and it was medically necessary to prevent further decline, etc. They put this in two or three lines in a billing manual update and gave an extreme example something like a patient with a fracture that was awaiting surgery that needed the skills to maintain bony alignment while performing ROM activities to prevent contractors. Of course it doesn't need to be that extreme, but they seem to like the scare tactics like sending out that letter to beneficiaries in Aug about the cap so they could avoid the manual review process. It has been that way for many years and most PTs don't know about it because they use the trickle down method of learning where things get left out or distorted when passed on from person to person, just like rumors. You can find the information in the federal register and medicare manuals if you do a diligent search. A few years later PT was also approved for hospice when there was no chance of recovery, it came down to a quality of life issue not a functional improvement requirement. I hope this helps others I'm sorry I cant provide a link or any other info, but you need to verify this on your own and pass it on...

Posted by Trevor D'Souza, PT
on 10/27/2012 12:33 PM

Hey Bryan, you should send it in before you reach the threshold not after. And don't have the patient sign an ABN like suggested in the webcast. It is crazy to think we should put Medicare beneficiaries on the hook for treatment we provide that we know is medically necessary. It defeats the purpose of the ABN, which is for non covered services, not ones that may arbitrarily get denied by the MAC. We need to fight these situations and not be backed into corners or make patients feel that they risk paying for services they need and Medicare is legally bound to cover.

Posted by Trevor D'Souza
on 10/27/2012 12:38 PM

From the information provided it appears this is a policy change that is in affect now. Will the APTA provide additional information on how we should incorporate this into our decision making process? Thank you!

Posted by Danielle Haggerty, PT
on 10/29/2012 1:26 PM

This is only half the battle. If the arbitrary cap stays in place, they will still be denied large amounts of care. Providers take all the risk, and I believe one CMS bulletin said that even if you do receive approval via the manual review process, they can come back years later and try to recoup the money.

Posted by Sean
on 10/30/2012 2:09 PM

does a tramatic brain injury qulify as a chronic condition for waiving the therapy cap?

Posted by diana
on 5/10/2013 9:24 AM

Does the new Medicare ruling on "improvement standards" for home health, specify that the treatment for "maintenance therapy" be carried out by a Physical Therapist (or an Occupational/Speech Therapist ) vs. a Physical Therapist Assistant (COTA/ST)? Or is the settlement policies still being addressed at this time?
Thank You

Posted by Sherri , PTA
on 8/27/2013 5:20 PM

Does the settlement on continued nursing care and physical therapy cover home bound patients?